Disclosed and described herein are systems and methods of performing computer-aided analysis of health claims to determine if a current claim is consistent with past claims for a member. Consistent claims are directed to a healthcare payor while non-consistent claims are returned for review and/or revision.
Legal claims defining the scope of protection, as filed with the USPTO.
2. The method of claim 1, wherein the sender is a healthcare provider and the recipient is a healthcare payor.
3. The method of claim 2, wherein the computer comprises a clearinghouse and the clearinghouse is configured to communicate claim messages between healthcare providers and healthcare payors.
4. The method of claim 1, wherein when it is determined that at least one of the set of expected diagnosis codes is not included in the portion of the current electronic health claim, then the method further comprises the computer identifying at least one of the expected diagnosis codes to include in the message based on at least one of frequency of the chronic diagnosis codes found in the prior diagnosis codes or recency of chronic diagnosis codes found in the prior diagnosis codes.
5. The method of claim 1, wherein when accessing, by the computer, the database of health claims, the computer only accesses and analyzes health claims associated with a defined period of time.
7. The method of claim 6, wherein the sender comprises a healthcare provider, and wherein the computer further utilizes one or more of a specialty of the healthcare provider, what other healthcare providers in that specialty often diagnose, and/or an amount of time spent by the healthcare provider with the member when identifying the set of expected diagnosis codes.
11. The system of claim 10, wherein the sender computer is associated with a healthcare provider and the recipient computer is associated with a healthcare payor.
12. The system of claim 11, wherein the computer comprises a clearinghouse and the clearinghouse is configured to communicate claim messages between healthcare providers and healthcare payors.
13. The system of claim 10, wherein when it is determined that at least one of the set of expected diagnosis codes is not included in the portion of the current electronic health claim, then the method further comprises the computer identifying at least one of the expected diagnosis codes to include in the message based on at least one of frequency of the chronic diagnosis codes found in the prior diagnosis codes or recency of chronic diagnosis codes found in the prior diagnosis codes.
14. The system of claim 13, wherein when accessing, by the computer, the database of health claims, the computer only accesses and analyzes health claims associated with a defined period of time.
16. The system of claim 15, wherein the sender computer is associated with a healthcare provider, and wherein the computer further executes computer-executable instructions to utilize one or more of a specialty of the healthcare provider, what other healthcare providers in that specialty often diagnose, and/or an amount of time spent by the healthcare provider with the member when identifying the set of expected diagnosis codes.
Cooperative Patent Classification codes for this invention. Click any code to explore related patents in that topic.
March 28, 2019
February 7, 2023
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